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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 12/01/2021
Date Signed: 12/01/2021 03:54:39 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2021 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210928104457
FACILITY NAME:SAN DIMAS RETIREMENT CENTERFACILITY NUMBER:
191500609
ADMINISTRATOR:PRISCILLA GAYTANFACILITY TYPE:
740
ADDRESS:834 WEST ARROW HIGHWAYTELEPHONE:
(909) 599-8441
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:343CENSUS: DATE:
12/01/2021
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Priscilla GaytanTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Resident went missing from facility.
Staff are harassing residents.
Facility is not testing residents after possible exposures.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted a subsequent complaint visit to deliver the findings. LPA met with the Marketing Coordiantor Melissa Hernandez and explained the reason of the visit and shortly after, the administrator Priscilla Gaytan arrived and assisted with the visit.

The investigation consisted of the following: On 10/06/21, LPA Irra conducted an initial 10 days complaint visit and obtained documents included: Resident Roster, Staff Roster (with contact information), List of new Resident Admissions for September 2021 and October 2021 (including "move outs"). Resident Trust Fund Report dated 10/01/21, List of Resident that recently changed to a new pharmacy and Special Incident Report related to latest COVID 19 (+) case from August 2021 (including notification provided to Residents, Staff, Responsible Parties). On 10/26/21, LPA Wong conducted a follow up visit and interviewed administrator, nine staff (S1-S9) and ten residents (R1-R10). During today's visit, LPA interviewed additional five (5) residents.
(See LIC 9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20210928104457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAN DIMAS RETIREMENT CENTER
FACILITY NUMBER: 191500609
VISIT DATE: 12/01/2021
NARRATIVE
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The investigation revealed of the following: Allegation#1 “Resident went missing from facility.” LPA interviewed staff and reported there were no resident went missing or AWOL recently. The administrator also reported the dementia unit is a secure unit and each staff needs to enter the code to go in and out. In addition, the alarm will be on if the door opened. LPA also reviewed the recent incident report from the facility and did not reveal any resident went missing from the facility during September and October 2021.

Allegation#2 “Staff are harassing residents.” LPA interviewed fourteen residents and they all reported staff never harassed them for changing the pharmacy. Some of the residents stated the staff only changed the pharmacy without noticing them. LPA interviewed staff and denied the allegation. They stated they never forced or harassed the residents about changing the pharmacy. They contacted the residents and responsible party about switching pharmacy only if the residents are willing to.

Allegation#3 “Facility is not testing residents after possible exposures.” LPA interviewed staff and reported there’s no exposures for residents and staff lately. It’s been few months already. LPA interviewed residents and reported they have not been tested for a while as they are all fully vaccinated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held. A copy of the report and appeal right was provided to administrator.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2021 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210928104457

FACILITY NAME:SAN DIMAS RETIREMENT CENTERFACILITY NUMBER:
191500609
ADMINISTRATOR:PRISCILLA GAYTANFACILITY TYPE:
740
ADDRESS:834 WEST ARROW HIGHWAYTELEPHONE:
(909) 599-8441
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:343CENSUS: DATE:
12/01/2021
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Priscilla GaytanTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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9
Facility is not providing residents an accounting of their funds.
Facility is not notifying residents of positive COVID results in facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Wong conducted a subsequent complaint visit to deliver the findings. LPA me with the Marketing Coordinator Melissa Hernandez and explained the reason of the visit and shortly after, the administrator Priscilla Gaytan arrived and assisted with the visit.

The investigation consisted of the following: On 10/06/21, LPA Irra conducted an initial 10 days complaint visit and obtained documents included: Resident Roster, Staff Roster (with contact information), List of new Resident Admissions for September 2021 and October 2021 (including "move outs"). Resident Trust Fund Report dated 10/01/21, List of Resident that recently changed to a new pharmacy and Special Incident Report related to latest COVID 19 (+) case from August 2021 (including notification provided to Residents, Staff, Responsible Parties). On 10/26/21, LPA Wong conducted a follow up visit and interviewed administrator, nine staff (S1-S9) and ten residents (R1-R10). On today’s visit, LPA also interviewed additional five (5) residents.
(See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20210928104457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SAN DIMAS RETIREMENT CENTER
FACILITY NUMBER: 191500609
VISIT DATE: 12/01/2021
NARRATIVE
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The investigation revealed of the following: Allegation#1: “Facility is not providing residents an accounting of their funds.” LPA interviewed residents and reported it took a long time for the staff to provide their trust account balance for them. It’s very difficult to obtain the account information from the staff. LPA interviewed staff and stated the resident only need to verbally request from the staff/bookkeeper in the facility. The staff is not behind anything about the trust account balance information. They are currently also working on providing quarterly report to residents.

Allegation#2 “Facility is not notifying residents of positive COVID results in facility.” LPA interviewed residents and reported staff only informed the residents the very first time last year that residents or staff had positive COVID cases. After that, they did not know anything about COVID positive cases. The facility never informed them or their responsible party. They only knew by the residents talked about it.


Based on the interviews conducted with the residents and documents reviewed, the preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are being cited on the attached LIC 9099D.

Exit interview held with administrator Priscilla Gaytan . A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20210928104457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SAN DIMAS RETIREMENT CENTER
FACILITY NUMBER: 191500609
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2021
Section Cited
CCR
87468.2(a)(19)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(19)(19) To have prompt access to review all of their records and to purchase photocopies of their records.
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The administrator will ensure the residents have prompt access to review of their records. The administrator will retrain the staff for residents' personal right and send the staff training log to LPA by POC due date.
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The requirement is not met as evidenced by LPA's interviewed with the residents. Residents reported it took a long time and very difficult o obtain their trust account balance information from staff which posed potential risk of the residents in care.
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Type B
12/15/2021
Section Cited
CCR
87468.1(a)(10)
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87468.1 Personal Rights of Residents in All Facilities (a) (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (10) To be informed of the licensee’s policy concerning visits and other communications with residents.
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The administrator will ensure the residents have the right to be informed the licensee policy of other communications with residents. The administrator will retrain the staff for residents' personal right and send the staff training log to LPA by POC due date
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The requirement is not met as evidenced by
LPA's interviews with the residents and reported they never got informed or notified about positive COVID results in facility.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5